Infectious Disease
Expert guidance on antimicrobial stewardship, emerging infections, and complex infectious disease management.
Recent Discussions
In what situations do you check for HIV status in your workup for inflammatory arthritis?
This brings up a great point - HIV screening is recommended for all patients at least once, and more frequently if the patient has risk factors for HIV. Seeing a patient in the clinic is a great opportunity to ensure they have been screened appropriately for HIV. In rheumatic disease situations, HIV...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...
How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?
In general, a history of splenectomy would lead to an increased concern regarding infections with parasitemia and encapsulated organisms (particularly Strep. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides). However, I would not consider prior splenectomy an absolute contraindi...
How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?
As an ophthalmologist, I will answer this selectively. The choice of immunomodulation for RA in the setting of liver dysfunction, I would defer to rheumatology (I do know that there are plenty of appropriate options that minimize risk to the liver). As far as the ocular HSV, I have many patients wit...